PRINCIPLES OF SKELETAL FIXATION

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PRINCIPLES OF SKELETAL FIXATION

• ANIL DUTTA, MD
• CDR MC USNR
• UTHSCSA ORTHOPEDICS

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• Fracture patterns
• Fracture healing
• Skeletal Fixation

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BONE

• Cortical Bone compact with osteons, lamellar
  bone
• Stronger, harder bone
• Cancellous Bone spongy, marrow spaces,
• softer

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BONE FAILURE

• FORCES COMPRESSION, TENSION, BENDING, TORSION

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FRACTURE PATTERNS

• TRANSVERSE
• OBLIQUE
• SPIRAL
• COMPRESSION

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FRACTURE PATTERNS
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FRACTURE LOCATION

• Diaphyseal
• Metaphyseal
• Articular
• Avulsion

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Bone Healing

• Primary Bone Healing Direct Cortical Healing
• Secondary Bone Healing enchondral ossification
  Hematoma, Soft Callous, Hard Callous, Remodeling

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PRIMARY BONE HEALING

• No cartilage formation
• No callous formation
• Cutting cones create channels for direct bone
  formation
• Also called Direct Cortical Healing, Direct Bone
  Healing

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Secondary Bone Healing

• 4 STAGES

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FRACTURE TREATMENT

• Historical
• Nothing
• Traction
• Splints
• Casting

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Traction
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CAST TREATMENT

• Hot Dog Principle

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Early Modern Era

• Plating Lane, Eggers
• External Fixation
• Intramedullary Nailing Kuntscher Nails

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FIXATION

• Internal Fixation
• Stable (plating, screws)
• Intramedullary Nailing/ pins
• Intraosseous Wiring
• External Fixation
• Circular External Fixators
• K- Wires- internal splint

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Rigidity/ Stability

• Rigidity The implants properties
• Stability A function of the fracture repairs
  construct
• Its better to have a construct that allows the
  bone to bear loads-
• It protects the implant from failure
• It improves the bones biological response

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AO/ASIF

• Rigid internal fixation to allow for early
  motion. Interfragmentary compression.
• Primary Bone Healing

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Direct Bone Healing
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METHODS OF FIXATION
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LAG SCREW
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NEUTRALIZATION
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TENSION BAND PLATING
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BUTTRESSING PLATE
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Anti-Glide Plate
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Bridge Plating
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Intra-articular Fixation
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I.M. Nailing

• Internal Splint
• Enchondral Ossification
• Reaming vs
• Unreamed

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External Fixation
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Locking Plate Technology

• Screws lock into plate
• Fixation in poor bone quality

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• K wires

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• Intraosseous
• Wiring

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Mechanical Failure

• Repeated loading leads to plate failure

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• Bone graft
• Increase mechanical
• stability

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NON-UNIONS

• Hypertrophic
• Atrophic
• Infected
• Malunion/ Non-Union

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NONUNIONS

• Direct compression

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Evaluation

• History
• Prior procedures, abx, cultures, NSAID usage,
  smoking, obesity, nutritional, medical conditions
• Ring J Trauma 2007 Predisposed are spiral/
  oblique and involve mid to prox third
• Physical Exam
• Motion, joint above and below, signs of
  infection,

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Evaluation Type of Nonunion

• Viable
• Hypertrophic
• Elephant foot, Horse foot
• Oligotrophic
• Blood supply without callous
• Nonviable
• Atrophic

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Types of Nonunions

• Infected
• Draining
• Active non-draining
• Quiescent
• Dead Space rotational vs free flap vs
  Papineau (Int Orthop79)
• Goals
• Union, Infection, deformity, function

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Evaluation

• LAB
• CBC, ESR, CRP,
• Albumin, Transferrin
• TLC gt 1500
• Albgt3.0 g/L
• HIV, Hep Panel
• Culture drainage, asp or biopsy (2 weeks off abx)

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Evaluation

• X-RAY deformity, surface characteristics,
  location
• (Center of Angle of Rotation CORA)
• CT
• Bone Scans
• Technetium 99m (viable vs non viable vs
  pseudoarthrosis)
• Indium-111
• Technetium 99m-HMPAO
• Gallium -67 Citrate (chronic inflammation)

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Evaluation

• Sinograms
• EMG/NCV
• Venous Doppler
• U/S

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s/p expandable nail 3 yrs ago
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Ex Fix with bone transport
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THANK YOU